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Breathlessness: A palliative care thread
“Breathe deeply, until sweet air extinguishes the burn of fear in your lungs and every breath is a beautiful refusal to become anything less than infinite” – D. Antoinette Foy
“Breathe deeply, until sweet air extinguishes the burn of fear in your lungs and every breath is a beautiful refusal to become anything less than infinite” – D. Antoinette Foy
History is everything here:
Symptoms:
Dyspnoea: the subjective sensation of breathlessness regardless of oxygen levels.
Precipitants/Alleviating factors
Cough, sputum, haemoptysis
Chest pain
Fever
Wheeze
Palpitations, oedema, orthopnoea
Symptoms:
Dyspnoea: the subjective sensation of breathlessness regardless of oxygen levels.
Precipitants/Alleviating factors
Cough, sputum, haemoptysis
Chest pain
Fever
Wheeze
Palpitations, oedema, orthopnoea
Most of us are good at this first part. We learn about it as we are training.
It can feel comfortable to stick to the symptoms but we must look beyond this.
Firstly: what impact does the breathlessness have on the patient?
It can feel comfortable to stick to the symptoms but we must look beyond this.
Firstly: what impact does the breathlessness have on the patient?
Breathlessness impact:
Daily activities: washing, dressing, walking, eating, drinking and sleeping.
Showering is often difficult due to enclosed space, heat and water on face
Occupation/identity loss of status or role (e.g as a parent/spouse) and financial insecurity
Daily activities: washing, dressing, walking, eating, drinking and sleeping.
Showering is often difficult due to enclosed space, heat and water on face
Occupation/identity loss of status or role (e.g as a parent/spouse) and financial insecurity
Ask what the breathlessness MEANS to the individual:
“I just know its my cancer getting worse”
“My treatment isn’t working is it?”
“I am scared I am going to die gasping for breath”
Such underlying beliefs should be explored gently but honestly.
“I just know its my cancer getting worse”
“My treatment isn’t working is it?”
“I am scared I am going to die gasping for breath”
Such underlying beliefs should be explored gently but honestly.
The fear of dying while breathless is very common but a very rare occurrence in reality.
Even the most severe states of breathlessness can be managed pharmacologically to bring comfort and relief.
Patients need to hear this as it can influence their preferred place of care.
Even the most severe states of breathlessness can be managed pharmacologically to bring comfort and relief.
Patients need to hear this as it can influence their preferred place of care.
The causes of breathlessness are numerous.
Let’s look at managing this in a general way then focus on some specific scenarios in palliative care.
First the non-pharmacological approaches
Let’s look at managing this in a general way then focus on some specific scenarios in palliative care.
First the non-pharmacological approaches
Position: sitting upright improves ventilation.
The tripod position (sitting forward leaning on outstretched hands on knees) fixes and lifts the shoulder girdle, improves the length–tension relationship of accessory muscles and optimises the use of the diaphragm.
The tripod position (sitting forward leaning on outstretched hands on knees) fixes and lifts the shoulder girdle, improves the length–tension relationship of accessory muscles and optimises the use of the diaphragm.
Environment:
Avoid extremes of temperature
Maintain ventilation and flow of air through the room- open windows.
Try a hand held fan if unable to get to a window. Cool moist are may activate the primitive diving reflex and reduce central respiratory drive
Avoid extremes of temperature
Maintain ventilation and flow of air through the room- open windows.
Try a hand held fan if unable to get to a window. Cool moist are may activate the primitive diving reflex and reduce central respiratory drive
Opioids
There is good evidence to support the use of morphine and to a lesser extent oxycodone for relief of breathlessness.
There is a lack of evidence for fentanyl, alfentanil and buprenorphine but anecdotally benefit has been observed.
There is good evidence to support the use of morphine and to a lesser extent oxycodone for relief of breathlessness.
There is a lack of evidence for fentanyl, alfentanil and buprenorphine but anecdotally benefit has been observed.
Some debate on which opioid preparations are best
Immediate release forms such as oramorph or shortec work well with predictable situations
e.g. using 5mg of oramorph 30 minutes before a shower or walk
Taking it when already breathless is too late in most situations.
Immediate release forms such as oramorph or shortec work well with predictable situations
e.g. using 5mg of oramorph 30 minutes before a shower or walk
Taking it when already breathless is too late in most situations.
For more persistent breathlessness a modified release preparation such as MST or Longtec usually works best.
An immediate release preparation can be used in conjunction with this for “breakthrough” or “incident” breathlessness just like with pain control.
An immediate release preparation can be used in conjunction with this for “breakthrough” or “incident” breathlessness just like with pain control.
Opioids are effective for relieving breathlessness at relatively low doses compared with pain relief.
Start low 2-5mg Immediate release morphine up to 4 tomes per day or 10mg modified release MST twoce daily.
Unusual to need more than 30-40mg of morphine/day for dyspnoea
Start low 2-5mg Immediate release morphine up to 4 tomes per day or 10mg modified release MST twoce daily.
Unusual to need more than 30-40mg of morphine/day for dyspnoea
Remember
Prescribe a laxative !!!
Ask “is it a safe option for this patient?”
Can they measure out their doses especially when breathless.
It’s not uncommon for some to swig their oramorph straight from the bottle- can someone drawn up doses in syringes for them?
Prescribe a laxative !!!
Ask “is it a safe option for this patient?”
Can they measure out their doses especially when breathless.
It’s not uncommon for some to swig their oramorph straight from the bottle- can someone drawn up doses in syringes for them?
Benzodiazepines
Use is for anxiety/panic accompanying breathlessness but opioids are first line.
Sublingual lorazepam 500micrograms is a popular option with patients. It works within 30mins and lasts up to 6-8hours.
Use is for anxiety/panic accompanying breathlessness but opioids are first line.
Sublingual lorazepam 500micrograms is a popular option with patients. It works within 30mins and lasts up to 6-8hours.
Diazepam has a much longer half life and can lead to excessive drowsiness especially in the elderly
Midazolam is fast acting and wears off quickly when given as subcutaneous injection.
It works very well in a continuous subcutaneous infusion for persistent, severe dyspnoea.
Midazolam is fast acting and wears off quickly when given as subcutaneous injection.
It works very well in a continuous subcutaneous infusion for persistent, severe dyspnoea.
Caution 
Take care with opioids and benzodiazepines. Go slowly!
Remember both can increase confusion, risk of falls and respiratory depression (COPD co2 retainers!)
Combining both drug types together needs careful montitoring especially in the elderly or in renal failure.
Take care with opioids and benzodiazepines. Go slowly!
Remember both can increase confusion, risk of falls and respiratory depression (COPD co2 retainers!)
Combining both drug types together needs careful montitoring especially in the elderly or in renal failure.
Oxygen
A trial of Oxygen for palliative of breathlessness can be considered on an individual basis for those with 02 saturations less than 92%
Home concentrators and back up cylinders can be ordered by senior respiratory and palliative care doctors. Delivery can be same day.
A trial of Oxygen for palliative of breathlessness can be considered on an individual basis for those with 02 saturations less than 92%
Home concentrators and back up cylinders can be ordered by senior respiratory and palliative care doctors. Delivery can be same day.
Corticosteroids
Would be a palliative thread without some Dexamethasone.
Superior vena cava obstruction
Lymphangitis carcinomatosis
Large airway obstruction including stridor
Bulky lung metastases
All are indications for a trial of Dexamethasone.
Often high dose 8-16mg/day
Would be a palliative thread without some Dexamethasone.
Superior vena cava obstruction
Lymphangitis carcinomatosis
Large airway obstruction including stridor
Bulky lung metastases
All are indications for a trial of Dexamethasone.
Often high dose 8-16mg/day
Give the steroids early in the day preferably after food. Use a PPI.
Insomnia is very common with higher doses, consider a low dose night sedation for a week.
Remember to monitor afternoon/evening blood glucose - see page 24-25 of this guidance
https://www.diabetes.org.uk/resources-s3/2018-03/EoL_Guidance_2018_Final.pdf?_gl=1*1q98im0*_ga*YW1wLW5keWoyQWNxM3h0S0xJN1pJUko1OWlWM0JhOEhuTUVUZVcwY1JkdlZGRU1VVzNiVzlPZUhON1lFVTdvN1VDVGU.
Insomnia is very common with higher doses, consider a low dose night sedation for a week.
Remember to monitor afternoon/evening blood glucose - see page 24-25 of this guidance
https://www.diabetes.org.uk/resources-s3/2018-03/EoL_Guidance_2018_Final.pdf?_gl=1*1q98im0*_ga*YW1wLW5keWoyQWNxM3h0S0xJN1pJUko1OWlWM0JhOEhuTUVUZVcwY1JkdlZGRU1VVzNiVzlPZUhON1lFVTdvN1VDVGU.
Stridor
High pitched noise on INSPIRATION
Due to upper airway obstruction
Emergency
Nebulised adrenaline 5mls of 1:1000
Heliox if available- better laminar flow
Dexamethasone 16mg IV/SCUT
Urgent ENT assistance for consideration of surgical airway if appropriate.
High pitched noise on INSPIRATION
Due to upper airway obstruction
Emergency
Nebulised adrenaline 5mls of 1:1000
Heliox if available- better laminar flow
Dexamethasone 16mg IV/SCUT
Urgent ENT assistance for consideration of surgical airway if appropriate.
Superior vena cava obstruction
Look for swollen hands and arms
Prominent veins on upper chest
Facial swelling/redness
Headache
Dysphagia
Dyspnoea
Emergency
Dexamethasone 16mg IV/SCUT
Contact oncology team
Radiotherapy, chemotherapy and/or stenting may be possible.
Look for swollen hands and arms
Prominent veins on upper chest
Facial swelling/redness
Headache
Dysphagia
Dyspnoea
Emergency
Dexamethasone 16mg IV/SCUT
Contact oncology team
Radiotherapy, chemotherapy and/or stenting may be possible.
Teamwork:
Respiratory/pleural teams:
Aspiration, chest drains, pleurodesis and indwelling pleural catheters (pleurex, Rocket) can provide rapid and reproducible relief in symptoms.
Cardiology:
AF, heart failure, pericardial effusion drainage, pacemakers
Respiratory/pleural teams:
Aspiration, chest drains, pleurodesis and indwelling pleural catheters (pleurex, Rocket) can provide rapid and reproducible relief in symptoms.
Cardiology:
AF, heart failure, pericardial effusion drainage, pacemakers
End of life
Similar principles apply
Opioids and benzodiazepines can be used and administered via syringe driver if oral route lost.
Make sure there are appropriate doses of PRN medications prescribed especially of risk of sudden breathless or airway obstruction
Similar principles apply
Opioids and benzodiazepines can be used and administered via syringe driver if oral route lost.
Make sure there are appropriate doses of PRN medications prescribed especially of risk of sudden breathless or airway obstruction
Remember that the degree of breathlessness, panic and anxiety rarely correlate with stage of disease.
These symptoms in themselves cause distress but usually pass.
Physiotherapy/Mindfulness and breathing techniques can accomplish more than any drug for some patients.
These symptoms in themselves cause distress but usually pass.
Physiotherapy/Mindfulness and breathing techniques can accomplish more than any drug for some patients.
